Routine inspection·February 10, 2023

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee Leah Archer. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA was screened by staff for Covid-19 which included a temperature check and signing in. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility continues to screen staff and residents and maintains documentation. Facility has a designated visitation area and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE and have been N95 fit tested. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication and incontinence care supplies. Facility has submitted their Emergency Disaster Plan, Infection Control Plan and Mitigation Plan. At approximate 8:30am LPA/staff observed fire extinguisher has not been serviced since December 2021. Also, approximate 9:00am LPA/staff observed toxins including disinfectants were unlocked and accessible to residents in care under the sink located in resident's bathroom. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Licensee provided copies of the following: LIC 308 Designated Administrative responsibility, LIC 500 Personnel Summary, Liability Insurance and lease agreement. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee and a copy of this report was provided.